Loading...
HomeMy WebLinkAbout3040 FALMOUTH ROAD/RTE 28 - Health (6) 3040 Bldg N FalmouthRoad (Rt 28) O q q' d3 6 _ 0W � _ Osterville P l o 't tf �gl 4 � 0 Commonwealth of Massachusetts D 9q- 6 3 0 ' GO Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"N" ; Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 03/20/19 page. Citylrown State Zip Code Date of Inspection ?� Inspection results must be submitted on this form. Inspection forms may not be altered in anyZ- way. Please see completeness checklist at the end of the form. Important:When A. Inspector Information 5 filling out forms on the computer, use only the tab Paul W. Davis key to move your Name of Inspector cursor-do not Rosano Davis Sanitary Pumping, Inc. use the return Company Name key. 9 Rocky Lane Company Address Cohasset MA 02025 City/Town State Zip Code 781-383-8888 SI 49 Telephone Number License Number B. Certification I certify that: I am a DEP approved system inspector in full compliance with Section 15.340 of Title 5 (310 CMR 15.000);1 have personally inspected the sewage disposal system at the property address listed above; the information reported below is true, accurate and complete as of the time of my inspection; and the inspection was performed based on my training and experience in the proper function and maintenance of on-site sewage disposal systems.After conducting this inspection I have determined that the system: 1. ® Passes 2. ❑ Conditionally Passes 3. ❑ Needs Further Evaluation by the Local Approving Authority 4. ❑ Fails 04/02/19 Inspector's Sig ture Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original form should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. Please note:This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 1 of 18 Commonwealth of Massachusetts uTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville required for every MA 02655 03/20/19 page. Cltyrrown State Zip Code Date of Inspection C. Inspection Summary Inspection Summary: Complete 1, 2, 3, or 5 and all of 4 and 6. 1) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: 2) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health,will pass. Check the box for"yes", "no"or"not determined"(Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND (Explain below): t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 2 of 18 Commonwealth of Massachusetts !F� Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/20/19 required for every � - page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 2) System Conditionally Passes(cunt.): ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND(Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): 3) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. a. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: t5insp.doc•rev.7126/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 18 Commonwealth of Massachusetts (P Title 5 official Inspection Form. '- Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owners Name information is Osterville required for every MA 02655 03/20/19 page. CltylTown State Zip Code Date of Inspection C. Inspection Summary (cont.) ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh b. System will fail unless the Board of Health (and.Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form. c. Other: 4) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ 0 Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 18 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/20/19 required for every � page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) 4) System Failure Criteria Applicable to All Systems: (cont.) Yes No ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than Y2 day flow ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public water supply well. - El Z Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ Z Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis,performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000 gpd- 10,000 gpd. ® The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. 5) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems,you must indicate.either"yes".or".no"to each of the following, in addition to the questions in Section CA. Yes No ❑ ® the system is within 400 feet of a surface drinking water supply ❑ ® the system is within 200 feet of a tributary to a surface drinking water supply ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well t5insp.doc•rev.7/26/2018 Title 5 official Inspection form:Subsurface Sewage Disposal System•Page 5 of 18 Commonwealth of Massachusetts p Title 5 Official Inspection Form < Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/20/19 required for every � page. Cityrrown State Zip Code Date of Inspection C. Inspection Summary (cont.) If you have answered"yes"to any question in Section C.5 the system is considered a significant threat, or answered°yes"to any question in Section CA above the large system has failed. The owner or operator of any large system considered a significant threat under Section C.5 or failed under Section CA shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. 6. You must indicate"yes"or"no"for each of the following for all inspections: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? Z ❑ Were as built plans of the system obtained and examined?(If they were not available note as N/A) Z ❑ Was the facility or dwelling inspected for signs of sewage back up? ❑ Was the site.inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper.maintenance.of.subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable)[310 CMR 15.302(5)] t5insp.doe•rev.7l2612018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 18 Commonwealth of Massachusetts UW Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/20/19 - page. Cltyrrown State Zip Code Date of Inspection D. System Information 1. Residential Flow Conditions: Number of bedrooms(design): 8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203(for example: 110 gpd x#of bedrooms): 880 gpd Description: Number of current residents: Varies Does.residence have a garbage grinder? ❑ Yes. ® No. Does residence have a water treatment unit? ❑ Yes Z No If yes, discharges to: Is laundry on a separate sewage system?(Include laundry system inspection information in this report.) ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Water meter readings were not available at time of inspection. Sump pump? ❑ Yes ® No Last date of occupancy: Current Date t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 18 Commonwealth of Massachusetts - Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owners Name information is OSterville required for every MA 02655 03/20/19 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 2. Commercial/industrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Water treatment unit present? ❑ Yes ❑ No If yes, discharges to: Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: Last date of occupancy/use: Date Other(describe below): 3. Pumping Records: Source of information: Condominium Association on semi-annual pumping schedule. Was system pumped as part of1he inspection? ® Yes .[] No If yes, volume pumped: 2,000 gallons gallons How was quantity pumped determined? Sight glass on pump truck. Reason for pumping: To determine structural integrity and watertightness of septic tank. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage.Disposal System•Page 8 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02665 03/20/19 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 4. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool.. ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) El Innovative/Alternative technology.Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank.Attach a copy of the DEP approval. ❑ Other(describe): Approximate age of all components, date installed(if known)and source of information: Previous inspections indicated installation in 1983 Were sewage odors detected when arriving at the site? ❑ Yes ® No 5. Building Sewer(locate on site plan): Depth below grade: 60" feet Material of construction: ❑cast iron ®40 PVC ❑other(explain): Schedule 40 PVC inlet pipe. Distance from private water supply well or suction line: No known wells in immediate are. feet Comments(on condition of joints, venting, evidence of leakage, etc.): Inlet pipe appeared to be clean and flowing freely. No evidence of leakage. t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 18 Commonwealth of Massachusetts U4(P Title 5 Official Inspection Fora Subsurface Sewage Disposal System Form-Not for Voluntary Assessments lC� Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/20/19 page. Cltyrrown State Zip Code Date of Inspection D. System Information (cont.) 6. Septic Tank(locate on site plan): Depth below grade: Inlet&outlet covers on risers to grade. Material of construction: 0 concrete ❑ metal ❑fiberglass ❑ polyethylene El other(explain) Precast concrete septic tank. If tank is metal, list age: years Is.age confirmed-by a Certificate.of-Compliance?(attach a copy of certificate) ❑ Yes. ❑. -No Dimensions: 6'wide x 4.5'deep x II'long 6 Sludge depth: Distance from top of sludge to bottom of outlet tee or baffle 24'° Scum thickness OWN Distance from top of scum to top of outlet tee or baffle 12" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured with a tape. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank was pumped at time of inspection. Tank was structurally sound and watertight and all effluent levels were at an appropriate height. Inlet and outlet tees in place. Recommend installing Zabel effluent filter in outlet tee to prevent solids from entering SAS. t5insp.doc•rev.7/26=18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/20/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 7. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date Comments(on pumping recommendations, inlet and outlet tee or baffle condition,structural integrity; liquid levels as related to outlet invert, evidence of leakage, etc.): 8. Tight or Holding Tank(tank must be pumped at time of inspection)(locate on site plan): . Depth below grade: Material of construction: ❑concrete ❑ metal ❑fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Capacity: gallons Design Flow: gallons per day t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/20/19 requiredforevery +. page. City(rown State Zip Code Date of Inspection D. System Information (cont.) 8. Tight or Holding Tank(cont.) Alarm present: ❑ Yes ❑ No Alarm level.' Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑j No 9. Distribution Box(if present must be opened) (locate on site plan): o., Depth of liquid level above outlet invert Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was structurally sound and watertight and providing even distribution of effluent into SAS. Carryover was moderate. There are no repairs recommended at this time. t5insp.doc-rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/20/19 requi�ed`forevery � page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) 10. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): *If pumps or alarms are not in working order, system is a conditional pass. 11. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: Type: ® leaching P� .Its number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow,cesspool number: ❑ innovative/alternative system Type/name of technology: t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 18 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/20/19 required for every � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) 11. Soil Absorption System (SAS)(cont.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation,,etc.): There was no surface wetness or breakout observed.There were no signs of hydraulic failure observed.SAS appeared to be in proper working order. Covers are cast iron to grade.There are no repairs recommended at this time. 12. Cesspools(cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc-rev.7/26Y2018 Title 5 Official Inspection form:Subsurface Sewage Disposal System•Page 14 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �rm' . .I Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02656 03/20/19 required for every � page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 13. Privy(locate on site plan): Materials of construction: Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5insp.doc•rev.7/26/2018 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 18 Commonwealth of Massachusetts UTitle 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655_ 03/20/19 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) 14. Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: hand-sketch in the area below ❑ drawing attached separately A .�a . Al a4t a 36� 3 65 j y 37' 131 3 7o y sari° t5insp.doc•rev.7/AM18 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 16 of 18 Commonwealth of Massachusetts � Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road,Osterville, MA BUILDING"N" lv V Property Address Multiple Owners Owner Owner's Name information is required for every Osteryille; MA 02656 03/20/10 page. Cityfrown State Zip Code Date of Inspection D. System Information (cont.) 15. Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: SEE BELOW feet, Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Previous inspections. ❑ Checked with local excavators, installers-(attach documentation) ❑. Accessed USGS database-explain: You must describe how you established the high ground water elevation: During a previous inspections the high ground water was indicated to be 22' below grade.This determination was by USGS ground water maps. It was by this non-intrusive method that it was estimated that separation exists from the bottom of the SAS and the seasonnally high ground water elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5insp.doc•rev.7126=18 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 18 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 03/20/19 page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist Complete.all applicable sections of this.form inclusive of: ® A. Inspector Information: Complete all fields in this section. ® B: Certification: Signed &Dated and 1, 2, 3, or 4 checked C. Inspection Summary: 1,2, 3, or 5 completed as appropriate 4(Failure Criteria)and 6(Checklist)completed ® D. System Information: For 8: Tight/Holding Tank-Pumping contract attached For 14: Sketch of Sewage Disposal System drawn on pg. 16 or attached For 15: Explanation of estimated depth to high groundwater included USGS maps and database - - - C55 . a WA:9 15insp.doc•rev.7/2612018 Title 5 official Inspection Form:Subsurface Sewage Disposal System•Page 18 of 18 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments , Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 09/18/14 page. Cityfrown State Zip Code Date of Inspection Inspection results must be submitted on this form. Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information on the computer, (_�I use only the tab 1. Inspector: key to move your cursor-do not Paul W. Davis use the return Name of Inspector key. Rosano Davis Sanitary Pumping, Inc. Company Name 9 Rocky Lane Company Address Cohasset MA 02025 Cityrrown State Zip Code 781-383-8888 SI49 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: ® Passes ❑ Conditionally Passes ❑ Fails ❑ Needs Further Evaluation by the Local Approving Authority 00/25/14 Inspector Signature Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. ID 3 I� t5ins-3/13 Title 5 Official Inspectif. : rface Sewage Disposal System Page 1 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes: ® I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass" section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health, will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank (whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y ❑ N ❑ ND :below (Explain ) t5ins-3113 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 Commonwealth of Massachusetts u Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 09/18/14 page. Cityfrown State Zip Code Date of Inspection B. Certification (cont.) ❑ Pump Chamber pumps/alarms not operational. System will pass with Board of Health approval if pumps/alarms are repaired. B) System Conditionally Passes (cont.): ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): ❑ distribution box is leveled or replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND(Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, safety and the environment: ❑ Cesspool or privy is within 50 feet of a surface water ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. CityrFown State Zip Code Date of Inspection B. Certification (cont.) 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well". Method used to determine distance: **This system passes if the well water analysis, performed at a DEP certified laboratory, for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: I D) System Failure Criteria Applicable to All Systems: You must indicate"Yes" or"No"to each of the following for all inspections: Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool ❑ ® Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool ❑ ® Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool ❑ ® Liquid depth in cesspool is less than 6" below invert or available volume is less than '/2 day flow t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 � - I Commonwealth of Massachusetts v Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM s Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville, MA 02655 09/18/14 requiredd for every page. CityTrown State Zip Code Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped: ❑ ® Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ ® Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ ® Any portion of a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility with a design flow of 2000gpd- 10,000gpd. ❑ ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. For large systems, you must indicate either"yes" or"no"to each of the following, in addition to the questions in Section D. Yes No ❑ ❑ the system is within 400 feet of a surface drinking water supply ❑ ❑ the system is within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ;M Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown State Zip Code Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no"as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health ❑ ® Were any of the system components pumped out in the previous two weeks? ® ❑ Has the system received normal flows in the previous two week period? ❑ ® Have large volumes of water been introduced to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth of liquid, depth of sludge and depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System (SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. ® ❑ Determined in the field (if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(5)] D. System Information Residential Flow Conditions: Number of bedrooms(design): 8 Number of bedrooms(actual): 8 DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 gpd t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 Commonwealth of Massachusetts . Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M . Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 09/18/14 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Unknown Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? (Include laundry system inspection ❑ Yes ® No information in this report.) Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage(gpd)): Detail: Water meter readings were not available at time of inspection. Sump pump? ❑ Yes ® No Last date of occupancy: Buildingoccupied. Commerciallindustrial Flow Conditions: Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments wM Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: Date Other(describe below): General Information Pumping Records: Source of information: Condo Association on semi-annual pumping schedule. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2,000 gallons gallons How was quantity pumped determined? Sight glass on pump truck. Reason for pumping: To determine structural integrity and watertightness of septic tank. Type of System: ® Septic tank, distribution box, soil absorption system ❑ Single cesspool ❑ Overflow cesspool ❑ Privy ❑ Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner)and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. ❑ Other(describe): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 8 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if known) and source of information: Previous inspections indicated installation in 1983. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): Depth below grade: 60"feet Material of construction: ❑ cast iron ®40 PVC ® other(explain): Schedule 40 PVC inlet pipe. Distance from private water supply well or suction line: No known wells in immediate area. Comments(on condition of joints, venting, evidence of leakage, etc.): Inlet pipe appeared to be clean and flowing freely. No evidence of leakage. Septic Tank(locate on site plan): Depth below grade: Covers to grade on inlet and outlet. Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast concrete septic tank with concrete cover on inlet and cast iron cover on outlet. Both covers are at grade. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No Dimensions: 6'wide X 4.5'deep X 11' long. Sludge depth: 6" t5ins•3/13 Tide 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 9 of 17 I Commonwealth of Massachusetts ✓ r Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments °M Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 09/18/14 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) Distance from top of sludge to bottom of outlet tee or baffle 24" Scum thickness 4" Distance from top of scum to top of outlet tee or baffle 8" Distance from bottom of scum to bottom of outlet tee or baffle 16" How were dimensions determined? Measured with a tape. Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank was pumped at time of inspection.Tank was structurally sound and watertight and all effluent levels were at an appropriate height. Inlet and outlet tees are in place.There are no other repairs recommended at this time. Grease Trap(locate on site plan): Depth below grade: feet Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: Scum thickness Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle i Date of last pumping: Date t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts W Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02656 09/18/14 page. CitylFown State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): i Tight or Holding Tank(tank must be pumped at time of inspection) (locate on site plan): Depth below grade: Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain): Dimensions: I Capacity: gallons Design Flow: gallons per day Alarm present: ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑ Yes ❑ No t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 11 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Osterville Pines-3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): Depth of liquid level above outlet invert 0" Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was structurally sound and watertight and providing even distribution of effluent. Carryover was moderate.There are no repairs recommended at this time. Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No* Alarms in working order: ❑ Yes ❑ No* Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.): * If pumps or alarms are not in working order, system is a conditional pass. Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why: t5ins-3/13 Title S.Official Inspection Form:Subsurface Sewage Disposal System-Page 12 of 17 r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ;M Osterville Pines -3040 Falmouth Road,Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Type: ® leaching pits number: 2 ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow cesspool number: ❑ innovative/alternative system Type/name of technology: Comments (note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no surface wetness or breakout observed.There were no signs of hydraulic failure observed. One pit was dry at time of inspection.The other pit had 24" of water in it. SAS appeared to be in proper working condition. Covers are cast iron to grade.There are no repairs recommended at this time. j Cesspools (cesspool must be pumped as part of inspection) (locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 13 of 17 Commonwealth of Massachusetts Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments �M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville, MA 02655 09/18/14 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy (locate on site plan): Materials of construction: Dimensions 11 Depth of solids Comments (note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M z Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A N 13 a a I� Cl M � 36' 3 y 3 7Li I 3 -7o' t5ins-3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 Commonwealth of Massachusetts W Title 5 official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments wM s Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Site Exam: ❑ Check Slope ❑ Surface water ❑ Check cellar ❑ Shallow wells Estimated depth to high ground water: SEE BELOW feet Please indicate all methods used to determine the high ground water elevation: ❑ Obtained from system design plans on record If checked, date of design plan reviewed: Date ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health-explain: Previous inspections. ❑ Checked with local excavators, installers-(attach documentation) ❑ Accessed USGS database-explain: You must describe how you established the high ground water elevation: During previous inspections the high groundwater was indicated to be 22' below grade.This determination was by USGS groundwater maps. It was by this non-intrusive method that it was estimated that separation exists from the bottom of the SAS and the seasonally high groundwater elevation. Before filing this Inspection Report, please see Report Completeness Checklist on next page. t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form _ Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 09/18/14 required for every � page. Cityrrown State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D, or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information—Estimated depth to high groundwater ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file USGS maps and database y y„ q t5ins•3/13 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 17 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form .l Subsurface Sewage Disposal System Form-Not for Voluntary Assessments' Osterville Pines -3040 Falmouth'Road, Osterville, MAr BUILDING N"Tj Property Address w r Multiple Owners Owner Owner's Name information is Osterville MA 02655 63/02/11 required for every , page. Citylrown State Zip Code Date of Inspection Inspection results must be submitted on this form.Inspection forms may not be altered in any way. Please see completeness checklist at the end of the form. Important:When filling out forms A. General Information ' on the computer, , use only the tab 1. Inspector. f key to move your - cursor-do not Paul W. Davis use the return Name of Inspector key. Rosario Davis Sanitary Pumping, Inc.. Company Name 9 Rocky Lane Company Address Cohasset MA 02025 Cityrrown-- 'State Zip Code 781-383-8888 SI49 Telephone Number License Number B. Certification I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true, accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000).The system: ® Passes ❑ Conditionally Passes ❑ Fails 4 ❑ Needs Further Evaluation b the Local Approving Authority - 03/15/11 Inspector's Sig ure Date The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater, the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to.the system'owner and copies sent to the buyer, if applicable, and the approving authority. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. t5ins•osioe Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal Sys t Page 1 0 17 P r Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Cityrrown State Zip Code Date of Inspection B. Certification (cont.) Inspection Summary: Check A,B,C,D or E/always complete all of Section D A) System Passes- ® I have not found any information which indicates that any of the failure criteria described in 316 CMR 15.303 or in 310 CMR 15.304-exist. Any failure criteria not evaluated are indicated below. Comments: B) System Conditionally Passes: ❑ One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system, upon completion of the replacement or repair, as approved by the Board of Health; will pass. Check the box for"yes", "no"or"not determined" (Y, N, ND)for the following statements. If"not determined," please explain. The septic tank is metal and over 20 years old*or the septic tank(whether metal or not) is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound, not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ❑ Y" ❑ N -❑ ND (Explain below): t5ins-ogios Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 2 of 17 L _ . Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines 3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name " information is required for every Osterville MA '02655 03/02/11 page. Cityrrown State Zip Code Date of Inspection. B. Certification (cont.) B) System Conditionally Passes.(cont.): i . ❑ Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipes) or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): 4 r ❑ broken pipe(s)are replaced ❑ Y ❑ N ❑ ND (Explain below): t . ❑ obstruction is removed ❑ 'Y ❑ N ❑ ND (Explain below): ❑ distribution box is leveled or replaced• ❑ Y ❑ N ❑ ND (Explain below): . ❑ The system required pumping more than 4 times a year due to broken or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): ❑ broken pipe(s) are replaced ❑ Y ❑ N ❑ ND (Explain below): ❑ obstruction is removed ❑ Y ❑ N ❑ ND (Explain below): C) Further Evaluation is Required by the Board of Health: ❑ Conditions exist which require further evaluation by the'Board of Health in order to determine if the system is failing to protect public health, safety or the environment.. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health, -safety and the environment: ; Cesspool or privy is within 50 feet of a surface water ' ❑ Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh t5ins•ogios Rosano Davis SanitaryPumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 3 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form , Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" _ Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. City/Town State Zip Code Date of Inspection B. Certification,(cont.) ' 2. System will fail unless the Board of Health (and Public Water Supplier, if any) determines that the system is functioning in a manner that protects the public health, safety and environment: ❑ The system has a septic tank and soil absorption system (SAS) and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. s ❑ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. ❑ The system has a septic tank and SAS and the SAS is less than 100 feet but 50'feet or more from a private water supply well". Method used to determine distance: '*This system passes if the well water analysis, performed at a DEP certified laboratory, for coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: D) System Failure Criteria Applicable to All Systems: w You must indicate"Yes" or."No to each of the following for all inspections: . Yes No ❑ ® Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool El Discharge or ponding of effluent to the surface of the ground or surface waters ® due to an overloaded or clogged_SAS or cesspool El ® ' Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool Liquid depth in cesspool is less than T.below invert or available volume is less ' ❑ ® than Y day flow t5ins•ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 4 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments s. Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 ' page. Cityrrown State 'Zip Code _Date of Inspection B. Certification (cont.) Yes No ❑ ® Required pumping more than 4 times in the last year NOT due to clogged or .obstructed pipe(s). Number of times pumped: ❑ ® .Any portion of the SAS, cesspool or privy is below high ground water elevation. ❑ ® Any portion of cesspool or privy-is within 100 feet of a surface water supply or tributary to a surface water supply. ❑ ® Any portion of a cesspool or privy is within a Zone 1 of a public well. ❑ N ' Any portion of a cesspool or privy is within 50 feet of a private water supply well. ❑ '® Any portion of-a cesspool or privy is less than 100 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for fecal coliform bacteria indicates absent and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis and chain of custody must be attached to this form.] ❑ ® The system is a cesspool serving a facility-with a design flow of 2000gpd- 10,000gpd. El ® The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303, therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E) Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. f For large systems, you must indicate either"yes"or"no"to each,of the following, in addition to the questions in Section D. Yes • No a 44 ❑ ❑ the system is within 400 feet of a surface drinking water'supply, ❑ El system is:within 200 feet of a tributary to a surface drinking water supply ❑ ❑ the system is located in a nitrogen sensitive area (Interim Wellhead Protection Area-IWPA) or a mapped Zone II of a public water supply well ' If you have answered "yes"to any question in Section E the system is considered a significant threat, or answered"yes" in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade_the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. t5ins"ogios Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System"Page 5 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments ,M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/02/11 required for every page. City/Town State Zip Code -Date of Inspection C. Checklist Check if the following have been done. You must indicate"yes" or"no" as to each of the following: Yes No ® ❑ Pumping information was provided by the owner, occupant, or Board of Health- Were any of the system components pumped out in the previous two weeks? ❑ Has the system received normal'flows in the previous two week period? ❑ ® Have large volumes of water been in to the system recently or as part of this inspection? ® ❑ Were as built plans of the system obtained and examined? (If they were not available"note as N/A) ® ❑ Was the facility or dwelling inspected for signs of sewage back up? ® ❑ Was the site inspected for signs of break out? ® ❑ Were all system components, excluding the SAS, located on site? ® ❑ Were the septic tank manholes uncovered, opened, and the'interior of the tank inspected for the condition of the baffles or tees, material of construction, dimensions, depth'of liquid, depth of sludge and'depth of scum? ® ❑ Was the facility owner(and occupants if different from owner) provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: ® ❑ Existing information. For example, a plan at the Board of Health. Z. ❑ Determined in the field (if any of the failure criteria,related to Part C is at issue approximation of distance is unacceptable) t310 CMR 15.302(5)] . 6 D. System Information Residential Flow Conditions: Number of bedrooms(design): 8 , Number of bedrooms(actual):, 8 DESIGN flow based on 310 CMR 15.203 (for example` 110 gpd x#of bedrooms):, . '880 gpd. t5ins•ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 6 of 17 r' Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville ' MA 02655 03/02/11 page. Citylrown State Zip Code Date of Inspection D. System Information Description: Number of current residents: Unknown. Does residence have a garbage grinder? ❑ Yes ® No Is laundry on a separate sewage system? [if yes separate inspection required] ❑ Yes ® No Laundry system inspected? ❑ Yes ❑ No Seasonal use? ❑ Yes ® No Water meter readings, if available(last 2 years usage (gpd)): Detail Water meter readings were not available at time of inspection. Sump pump? ❑ Yes ® No Last date of occupancy: 03/02/11 -Building occupied.- Commercial/industrial Flow Conditions: 1 Type of Establishment: Design flow(based on 310 CMR 15.203): Gallons per day(gpd) 3 Basis of design flow(seats/persons/sq.ft., etc.): Grease trap present? ❑ Yes ❑ No Industrial waste holding tank present? ❑ Yes ❑ No Non-sanitary waste discharged to the Title 5 system? ❑ Yes ❑ No Water meter readings, if available: t5ins•osioe Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 7 of 17 Commonwealth of Massachusetts Title 5 Official Inspection" Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address , Multiple Owners ^ Owner Owner's Name information is Osterville R MA 02655 03/02/11 required for every page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Last date of occupancy/use: - Date Other(describe below): General Information Pumping Records: Source of information: Condo Association on yearly maintenance schedule. Was system pumped as part of the inspection? ® Yes ❑ No If yes, volume pumped: 2,000 gallons gallons How was quantity pumped determined? Sight glass on pump truck. Reason for pumping: Yearly maintenance&to determine structural integrity &watertightness of septic tank. Type of System: ® Septic tank,distribution box,,soil-absorption system ❑ Single cesspool . ❑ Overflow cesspool ❑ Privy f ❑' Shared system (yes or no) (if yes, attach previous inspection records, if any) ❑ Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) and a copy of latest inspection of the I/A system by system operator under contract ❑ Tight tank. Attach a copy of the DEP approval. " ❑ Other(describe): t5ins•ogioe Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 8 of 17 i Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/02/11 required for every page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Approximate age of all components, date installed (if,known) and source of information: Installed approximately in 1983 per previous inspection. Were sewage odors detected when arriving at the site? ❑ Yes ® No Building Sewer(locate on site plan): • 60,E Depth below grade: feet Material of construction: ❑ cast iron ® 40 PVC Schedule 40 PVC inlet pipe. ❑ other(explain): . No known wells in area. Distance from private water supply well or suction line: feet Comments(on condition of joints, venting, evidence of leakage, etc.): All piping appeared to be clean and flowing freely. No evidence of leakage. Septic Tank(locate on site plan): Depth below grade: .Covers to grade on inlet&outlet. feet Material of construction: ® concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑ other(explain) Precast concrete septic tank with concrete cover to grade on inlet and cast iron cover to grade , on outlet. If tank is metal, list age: years Is age confirmed by a Certificate of Compliance? (attach a copy of certificate) ❑ Yes ❑ No i Dimensions: , 6'wide X 4.5' deep X 11' long. Sludge depth: t5ins•09/08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 9 of 17 Commonwealth of Massachusetts ; Title 5 Official Inspection Form p . Subsurface Sewage Disposal System Form-Not for Voluntary Assessments ��M y Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Cityrrown State Zip Code Date of Inspection D. System Information (cont.) Septic Tank(cont.) e + Distance from top of sludge to bottom'of outlet tee or baffle 24" Scum thickness , 4" Distance from top of scum to top of outlet tee or baffle 8 Distance from bottom of scum to bottom of outlet tee or baffle 16" q How were dimensions determined? Measured with a tape. Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage, etc.): Septic tank was pumped at time of inspection. Tank was structurally sound and watertight and all effluent levels were at an appropriate height. Inlet and outlet tees in place.There are no repairs recommended at this time. Grease Trap (locate on site plan): Depth below grade: feet _ a ' Material of construction: ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene ❑.other(explain): Dimensions: ' 4 Scum thickness t Distance from top of scum to top of outlet tee or baffle Distance from bottom of scum to bottom of outlet tee or baffle Date of last pumping: Date t5ins.og/oa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 10 of 17 Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA. .BUILDING"N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence,of leakage, etc.): Tight or Holding Tank(tank must be;pumped at time of inspection) (locate on site plan)` Depth below grade: Material of construction: ' ❑ concrete ❑ metal ❑ fiberglass ❑ polyethylene El,other(explain): Dimensions: Capacity: gallons Design Flow' gallons per day Alarm present: t ❑ Yes ❑ No Alarm level: Alarm in working order: ❑ Yes ❑ No Date of last pumping: Date Comments(condition of alarm and float switches, etc.): *Attach copy of current pumping contract(required). Is copy attached? ❑-Yes ❑ No. y ' t5ins•ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 11 of 17 > - a, Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 03/02/11 page. Citylrown State Zip Code Date of Inspection D. System Information (cont.) Distribution Box(if present must be opened) (locate on site plan): of, Depth of liquid level above outlet invert Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover, any evidence of leakage into or out of box, etc.): Box was structurally sound and watertight and providing even distribution of,effluent. Carryover was moderate. There are no repairs recommended at this time Pump Chamber(locate on site plan): Pumps in working order: ❑ Yes ❑ No Alarms in working order: ❑ Yes. ❑ No Comments(note condition of pump chamber, condition of pumps and appurtenances, etc.) Soil Absorption System (SAS) (locate on site plan, excavation not required): If SAS not located, explain why:" x , t5ins•69/08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 12 of 17 1. Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form -Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING N Property Address Multiple Owners Owner Owner's Name information is Osterville MA 02655 03/02/11 required for every • page. Citylrown State Zip Code - Date of Inspection D. System Information (cont.) Type. ® leaching pits number: 2 - leaching pits. ❑ leaching chambers number: ❑ leaching galleries number: ❑ leaching trenches number, length: ❑ leaching fields number, dimensions: ❑ overflow,cesspool number: . a ❑ innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure, level of ponding, damp soil, condition of vegetation, etc.): There was no surface wetness, breakout or signs'of hydraulic failure observed. One pit was dry and the other pit had 20" of water in it. Covers are cast iron to grade. Leaching appears to be in proper working condition.There are no repairs recommended at this time. -Cesspools (cesspool must be pumped as part of inspection)(locate on site plan): Number and configuration Depth—top of liquid to inlet invert Depth of solids layer Depth of scum layer - Dimensions of cesspool Materials of construction Indication of groundwater inflow ❑ Yes ❑ No • k t5ins•.ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System°Page 13 of 17 w L Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments �M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N' Property Address Multiple Owners Owner Owner's Name `A - information is Osterville MA 02655 03/02/11 required for every fi page. City/Town State Zip Code Date of Inspection D. System Information (cone.) Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): Privy(locate on site plan): Materials of construction: , Dimensions Depth of solids Comments(note condition of soil, signs of hydraulic failure, level of ponding, condition of vegetation, etc.): , i t5ins•ogioa Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 14 of 17 Cb f Commonwealth of Massachusetts Title 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments M Osterville Pines -3040 Falmouth Road, Osterville, MA BUILDING "N" Property Address Multiple Owners Owner Owner's Name - information is required for every Osterville MA 02655 03/02/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Sketch Of Sewage Disposal System: Provide a view of the sewage disposal system, including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet. Locate where public water supply enters the building. Check one of the boxes below: ® hand-sketch in the area below ❑ drawing attached separately A 13 A . • " . CJa � AI a4t . 3 65, y 37' Oy O@3 Q , 071 Lill 3 7ol t5ins•'Og/OS Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 15 of 17 ' Commonwealth of Massachusetts Title• 5 Official Inspection Form Subsurface Sewage Disposal System Form - Not for Voluntary Assessments Osterville Pines -3040 Falmouth Road,'Osterville, MA'- BUILDING"N'' Property Address Multiple Owners Owner Owner's Name information is required for every Osterville MA 02655 } 03/02/11 page. City/Town State Zip Code Date of Inspection D. System Information (cont.) Site Exam: F ❑ Check Slope ❑ Surface water ❑ Check cellar f ❑ Shallow wells Estimated depth to high ground water: SEE BELOW feet Please indicate all methods used to determine the'high ground water elevation: a • r ❑ Obtained from system design plans on record , If checked, date of design plan reviewed: pate ❑ Observed site(abutting property/observation hole within 150 feet of SAS) ® Checked with local Board of Health -explain: Previous inspections. ' ❑ Checked with local excavators;-installers-(attach documentation) ❑ r Accessed USGS database-explain: • M You must describe how you established the high ground water elevation: During a previous inspection the high groundwater was indicated to be 22' below grade.This determination was by USGS groundwater maps. It was by this non-intrusive method that it was estimated that separation exists from the bottom of the SAS and the high groundwater. t f • . Before filing this Inspection Report, please see Report Completeness Checklist on next page. i5ins•09/08 Rosano Davis Sanitary Pumping,Inc 781-383-8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System•Page 16 of 17 Commonwealth of Massachusetts = . Title- 5 Official Inspection Form Subsurface Sewage Disposal System Form-Not for Voluntary Assessments GSM , Osterville Pines -3040 Falmouth-Road, Osterville, MA BUILDING"N" - Property Address F Multiple Owners - Owner Owner's Name information is Osterville MA „ 02655 . • 03/02/11 required for every k page. City/Town State Zip Code Date of Inspection E. Report Completeness Checklist ® Inspection Summary: A, B, C, D,,or E checked ® Inspection Summary D (System Failure Criteria Applicable to All Systems)completed ® System Information— Estimated depth to high groundwater' ® Sketch of Sewage Disposal System either drawn on page 15 or attached in separate file j USGS maps and database TLI .T_ WA":4i? .,..� .._._._._...._... ,..-_.____ -- -•-�---•'_tea_..._T....----• �-.- -..---•-- --- • i t5ins•0 o8 Rosano Davis Sanitary Pumping,Inc +781-383r8888 Title 5 Official Inspection Form:Subsurface Sewage Disposal System-Page 17 of 17 Imo_ _ - .. .. +. • - COMMONWEALTH OF MASSACHUSETTS �y/� EXECUTIVE OFFICE OF ENVIRONMENTAL AFFAIRS 'ro'p 4 s F SARNS TABLE. d DEPARTMENT OF ENVIRONMENTAL PROTECTION .ip 2 01H MAP 29 P?i 3: 58 PARCEL Lar �ee- DIVISION TITLE 5 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM PART A CERTIFICATION Property Address: 3040 Falmouth Road,Osterville Pines,Bldg N ��'7 Owner's Name: Osterville Pines Condo Trust,c/o Huntingest Management Owner's Address: 40 Industry Rd,Marstons Mills,MA 02648 Date of Inspection:02/20/05 Name of Inspector:Brian T.Axon Company Name:A&K Septic Systems Plus Mailing Address: 565 Carriage Shop Road,East Falmouth,MA 02536 Telephone Number: 508-540-6706 CERTIFICATION STATEMENT I certify that I have personally inspected the sewage disposal system at this address and that the information reported below is true,accurate and complete as of the time of the inspection. The inspection was performed based on my training and experience in the proper function and maintenance of on site sewage disposal systems. I am a DEP approved system inspector pursuant to Section 15.340 of Title 5(310 CMR 15.000). The system: X Passes Conditionally Passes Needs Further Evaluation by the Local Approving Authority Fails Inspector's Signature: Date: 03/08/05 The system inspector shall submit a copy of this inspection report to the Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the DEP. The original should be sent to the system owner and copies sent to the buyer,if applicable, and the approving authority. Notes and Comments: System functioning fine. There is no evidence of failure criteria. System consists of 2000 gallon septic tank with d-box and 2-1000 gallon precast leaching pits. ****This report only describes conditions at the time of inspection and under the conditions of use at that time.This inspection does not address how the system will perform in the future under the same or different conditions of use. I T Page 2 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address:3040 Falmouth Rd,Osterville Pines,Bldg N Owner: Osterville Pines Condominium Trust Date of Inspection: 02/20/05 Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. System Passes: X I have not found any information which indicates that any of the failure criteria described in 310 CMR 15.303 or in 310 CMR 15.304 exist. Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired. The system,upon completion of the replacement or repair,as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements.If"not determined"please explain. The septic tank is metal and over 20 years old* or the septic tank(whether metal or not)is structurally unsound, exhibits substantial infiltration or exfiltration or tank failure is imminent. System will pass inspection if the existing tank is replaced with a complying septic tank as approved by the Board of Health. *A metal septic tank will pass inspection if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. ND explain: Observation of sewage backup or break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken, settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distribution box is leveled or replaced ND explain: The system required pumping more than 4 times a year due to broken"or obstructed pipe(s). The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: f Page 3 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3040 Falmouth Rd,Osterville Pines,Bldg N Owner: Osterville Pines Condominium Trust Date of Inspection: 02/20/05 C. Further Evaluation is Required by the Board of Health: Conditions exist which require further evaluation by the Board of Health in order to determine if the system is failing to protect public health, safety or the environment. 1. System will pass unless Board of Health determines in accordance with 310 CMR 15.303(1)(b)that the system is not functioning in a manner which will protect public health,safety and the environment: Cesspool or privy is within 50 feet of a surface water Cesspool or privy is within 50 feet of a bordering vegetated wetland or a salt marsh 2. System will fail unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a manner that protects the public health,safety and environment: _ The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone 1 of a public water supply. _ The system has a septic tank and SAS and the SAS is within 50 feet of a private water supply well. _ The system has a septic tank and SAS and the SAS is less than 100 feet but 50 feet or more from a private water supply well".Method used to determine distance "This system passes if the well water analysis,performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered. A copy of the analysis must be attached to this form. 3. Other: Page 4 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: 3040 Falmouth Rd,Osterville Pines,Bldg N Owner: Osterville Pines Condominium Trust Date of Inspection: 02/20/05 D. System Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspections: Yes No X Backup of sewage into facility or system component due to overloaded or clogged SAS or cesspool , x Discharge or ponding of effluent to the surface of the ground or surface waters due to an overloaded or clogged SAS or cesspool x Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or cesspool x Liquid depth in cesspool is less than 6"below invert or available volume is less than 1/z day flow x Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped x Any portion of the SAS, cesspool or privy is below high ground water elevation. x Any portion of cesspool or privy is within 100 feet of a surface water supply or tributary to a surface water supply. x Any portion of a cesspool or privy is within a Zone 1 of a public well. x Any portion of a cesspool or privy is within 50 feet of a private water supply well. x Any portion of a cesspool or privy is less than 160 feet but greater than 50 feet from a private water supply well with no acceptable water quality analysis. [This system passes if the well water analysis, performed at a DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen is equal to or less than 5 ppm,provided that no other failure criteria are triggered.A copy of the analysis must be attached to this form.] I ° no (Yes/No)The system fails.I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,therefore the system fails. The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a large system the system must serve a facility with a design flow of 10,000 gpd to 15,000 gpd. You must indicate either"yes"or"no"to each of the following: (The following criteria apply to large systems in addition to the criteria above) yes no the system is within 400 feet of a surface drinking water supply the system is within 200 feet of a tributary to a surface drinking water supply the system is located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the:system is considered a significant threat,or answered "yes"in Section D above the large system has failed. The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade the system in accordance with 310 CMR 15.304. The system owner should contact the appropriate regional office of the Department. I Page 5 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART B . CHECKLIST Property Address:3040 Falmouth Road,Osterville Pines,Bldg N Owner: Osterville Pines Condominium Trust Date of Inspection:02/20/05 Check if the following have been done. You must indicate"yes"or"no"as to each of the following: Yes No X _ Pumping information was provided by the owner,occupant,or Board of Health x ere any of the system components pumped out in the previous two weeks? x Has the system received normal flows in the previous two week period? x Have large volumes of water been introduced to the system recently or as part of this inspection? x Were As Built plans of the system obtained and examined?(If they were not available note as N/A) x _ Was the facility or dwelling inspected for signs of sewage back up? x _ Was the site inspected for signs of break out? j x Were all system components,excluding the SAS, located on site? x _ Were the septic tank manholes uncovered, opened,and the interior of the tank inspected for the condition of the baffles or tees,material of construction,dimensions,depth of liquid,depth of sludge and depth of scum? x _ Was the facility owner(and occupants if different from owner)provided with information on the proper maintenance of subsurface sewage disposal systems? The size and location of the Soil Absorption System(SAS)on the site has been determined based on: Yes no x _ Existing information.For example, a plan at the Board of Health. x _ Determined in the field(if any of the failure criteria related to Part C is at issue approximation of distance is unacceptable) [310 CMR 15.302(3)(b)] i Page 6ofII OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C i SYSTEM INFORMATION Property Address: 3040 Falmouth Road, Osterville Pines,Bldg N Owner: Osterville Pines Condominium Trust Date of Inspection: 02/20/05 FLOW CONDITIONS RESIDENTIAL Number of bedrooms(design): 8 Number of bedrooms(actual) : 8 4—2 bedroom units DESIGN flow based on 310 CMR 15.203 (for example: 110 gpd x#of bedrooms): 880 Number of current residents: 7 Does residence have a garbage grinder(yes or no): no Is laundry on a separate sewage system(yes or no):no[if yes separate inspection required] Laundry system inspected(yes or no): no Seasonal use: (yes or no): no Water meter readings, if available(last 2 years usage(gpd)): Sump pump(yes or no):no Last date of occupancy: current COMMERCIALANDUSTRIAL Type of establishment: Design flow(based on 310 CMR 15.203): gpd Basis of design flow(seats/persons/sgft,etc.): Grease trap present(yes or no):_ Industrial waste holding tank present(yes or no):= Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER(describe): s GENERAL INFORMATION Pumping Records Source of information: system on regular maintenance schedule Was system pumped as part of the inspection(yes or no):no If yes,volume pumped:,How was quantity pumped determined? Reason for pumping: TYPE OF SYSTEM X Septic tank, distribution box, soil absorption system _Single cesspool _Overflow cesspool _Privy _Shared system(yes or no)(if yes, attach previous inspection records,if any) _Innovative/Alternative technology. Attach a copy of the current operation and maintenance contract(to be obtained from system owner) _Tight tank _Attach a copy of the DEP approval _Other(describe): Approximate age of all components, date installed(if known)and source of information: installed roughly 1983 Were sewage odors detected when arriving at the site(yes or no): no L Page 7 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3040 Falmouth Road,Osterville Pines,Bldg N Owner: Osterville Pines Condominium Trust Date of Inspection: 02/20/05 t BUILDING SEWER(locate on site plan) Depth below grade: Materials of construction:_cast iron 40 PVC_other(explain): Distance from private water supply well or suction line: Comments(on condition of joints,venting,evidence of leakage,etc.): SEPTIC TANK x (locate on site plan). Depth below grade: roughly 40" Material of construction: x concrete_metal_fiberglass_polyethylene _other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no):—(attach a copy of certificate) Dimensions: 12.5'x 6' x 5' Sludge depth: 6" Distance from top of sludge to bottom of outlet tee or baffle: 32" Scum thickness: 4" Distance from top of scum to top of outlet tee or baffle: 8" Distance from bottom of scum to bottom of outlet tee or baffle:16" How were dimensions determined: field instruments Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage, etc.):Recommend pumping every two years. Liquid levels in relation to tees are fine. There is no evidence of leakage. Cover to grade. GREASE TRAP: NA(locate on site plan) Depth below grade: Material of construction:_concrete_metal fiberglass_polyethylene_other (explain): Dimensions: Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert,evidence of leakage,etc.): r_ 1 I Page 8 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3040 Falmouth Road,Osterville Pines,Bldg N Owner:Osterville Pines Condominium Trust Date of Inspection: 02/20/05 TIGHT or HOLDING TANK: NA (tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass_polyethylene other(explain): Dimensions: Capacity: gallons Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments(condition of alarm and float switches, etc.): DISTRIBUTION BOX: X (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: workingl evel Comments(note if box is level and distribution to outlets equal, any evidence of solids carryover,any evidence of leakage into or out of box, etc.):No sign of solids carryover or any evidence of leakage.Depth of liquid at working level PUMP CHAMBER: NA(locate on site plan) Pumps in working order(yes or no): Alarms in working order(yes or no): Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): Page 9 of 11 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3040 Falmouth Road,Osterville Pines,Bldg N Owner: Osterville Pines Condominium Trust Date of Inspection: 02/20/05 SOIL ABSORPTION SYSTEM(SAS): x (locate on site plan,excavation not required) If SAS not located explain why: Type X leaching pits, number: 2 leaching chambers, number: leaching galleries, number: leaching trenches,number, length: leaching fields, number, dimensions: overflow cesspool,number: innovative/alternative system Type/name of technology: Comments(note condition of soil, signs of hydraulic failure,level of ponding,damp soil, condition of vegetation, etc.): 2-1000 gallon precast leaching pits show no signs of hydraulic failure. Covers are to grade and top of pits are about 44"to grade CESSPOOLS:_NA (cesspool must be pumped as part of inspection)(locate on site plan) Number and configuration: Depth—top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no):" Comments(note condition of soil, signs of hydraulic failure,level of ponding,condition of vegetation, etc.): i i PRIVY: NA (locate on site plan) Materials of construction: Dimensions: Depth of solids: Comments(note condition of soil, signs of hydraulic failure,level of ponding, condition of vegetation, etc.): J Page 10 of 11 OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) . Property Address: 3040 Falmouth Road,Osterville Pines,Bldg N Owner: Osterville Pines Condominium Trust Date of Inspection: 02/23/05 SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system including ties to at least two permanent reference landmarks or benchmarks.Locate all wells within 100 feet.Locate where public water supply enters the building. A ❑ a41 ,41 psi y °3 7 13 �71 Lll' Page I 1 of l 1 j !' OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: 3040 Falmouth Road,Osterville Pines,Bldg N Owner: Osterville Pines Condominium Trust Date of Inspection: 02/20/05 SITE EXAM Slope Surface water Check cellar Shallow wells Estimated depth to ground water 22 feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed.- Observed site(abutting property/observation hole within 150 feet of SAS) Checked with local Board of Health-explain: Checked with local excavators,installers-(attach documentation) x Accessed USGS database-explain.- You must describe how you established the high ground water elevation: USGS maps and database 1 yyo� tsJa::4 i. {I COMMONWEALTH OF MASSACHUSETTS EXECUTIVE,OFFICE OF ENVIRONMENTAL AFFAIRS DEPARTMENT OF ENVIRONMENTAL PROTECTaI�'IVD FEB 1`5 2002 TOWN OF BARNSTABLE HEALTH DEPT.. TITLE S OFFICIAL INSPECTION FORM NOT FOR YOLUNTARY ASSESSMENTS . SUBSURFACE SEWAGE DISPOSAL SYSTEM FORM` PART A CERTIFICATION Property Address: Owner's Name: 7 O•��0z x JL �clJ7 t � Owner's Address: v' Uhl e��f` Date of Inspection: se hO n ��f1CJ r Name of Inspector: leas print) i . ► h (Ult`h 1. Company Name l�. 11. 1 )' S 159nL Mailing Address: v Telephone Number:,:�62-` 91_C??13 CERTIFICATION STATEMENT- I certify that I have personally inspected the sewage disposal system at this ad ress.and that the information reported below is true, accurate and:complete as of the time of the inspection. The inspection was performed based on my traininc and experience in the proper function and maintenance of on site sewage disposal systems.I am a DEP approved system inspector pursuant to ection 15.340 of Title 5(310 CMR 15.00.0). The system:, Passes Conditionally.Passes Needs.Further Evaluation by the Local Approvin-.Authority /l,F Is Inspector's Signature: Date: / Cl The system inspector shall submit a copy,of this inspection report,to the.Approving Authority(Board of Health or DEP)within 30 days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to the appropriate regional office of the. DEP.The original should be sent to the system owner and copies sent to the buyer, if applicable; and the approving authority. ` Notes and Comments ****This report only describes conditions at the.time of inspection..and.under:the conditions of use at that time. This inspection does not addre',ss how the system will.perform in the future under the same or different conditions of use. f Title 5 Inspection Form 6/15/2000 page l Page 2 of 11 OFFICIAL INSPECTION FORM.—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE`SEWAGFDISPOStAL SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) Property Address: c3_ ,0X?,a, ���� Owner: / Date of Inspection: �.A1WaA 744 /..'C7CJ Inspection Summary: Check A,B,C,D or E/ALWAYS complete all of Section D A. (System Passes: V I have'not found any information which indicates that any of the:failure criteria-described in 310 CMR 15.303 or in 310 CMR 15.304 exist.Any failure criteria not evaluated are indicated below. Comments: B. System Conditionally Passes: One or more system components as described in the"Conditional Pass"section need to be replaced or repaired.The system,upon completion•ofthe replacement or repair, as approved by the Board of Health,will pass. Answer yes,no or not determined(Y,N,ND)in the for the following statements. If"not determined".please explain. The septic tank is metal and over 20 years:old*or the septic tank(whether metal or not) is structurally unsound,exhibits substantial infiltration or exfiltration or tank failure is_imminent. System will pass inspection if the existing tank is replaced with a.complying septic tank as-approved by the Board of Health. *A metal septic tank will pass inspection.if it is structurally sound,not leaking and if a Certificate of Compliance indicating that the tank is less than 20 years old is available. . ND-explain: Observation of sewage backup or-break out or high static water level in the distribution box due to broken or obstructed pipe(s)or due to a broken,settled or uneven distribution box. System will pass inspection if(with approval of Board of Health): broken pipe(s)are replaced obstruction is removed distributionboa is leveled or replaced ND explain: The system-required pumping more than'4 times a year due to broken or obstructed pipe(s),'The system will pass inspection if(with approval of the Board of Health): broken pipe(s)are replaced obstruction is removed ND explain: 2 Page 3 of I'1 OFFICIAL,INSPECTION FORM-NOT FOR VOLUNTARY'ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL.SYSTEM INSPECTION FORM PART A CERTIFICATION(continued) . Property Address: . ./V• 1ec oe Owner: Date of Inspection: C. Further Evaluation is Required by the Board of Health: ` Conditions exist which require further evaluation by the Board of Health in order to'determine.if the systern' is failing to protect public health, safety or the.environment: 1. System.w'ill pass unless Board of Health determines in accordance with 310 CMR-15.303(1)(b)that the. system is not.functioning m a manner which will protect public health,safety and the.environment: — Cesspool or privy is within-50 feet of.a surface water — Cesspool or privy is within 50,feet of a bordering vegetated wetland or a salt marsh 2. System will fail.unless the Board of Health(and Public Water Supplier,if any)determines that the system is functioning in a.manner that protects the.public health;safety and environment: .The system has a septic tank and soil absorption system(SAS)and the SAS is within 100 feet of a surface water supply or tributary to a surface water supply. The system has a septic tank and SAS and the SAS is within a Zone I of a,public water.supply. The system has a septic tank and SAS and the SAS is within`50 feetofa private-water supply well. The system has aseptic tank and SAS and.the SAS is less than 100.,feet but 50.feet or more from a. private water supply well**. Method used to determine distance. "This system passes if the well,water analysis;performed at a DEP'certified laboratory; for colifor m bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is.equal to or less than 5 ppm,provided that no other failure criteria are triggered. A,copy of the.analysis must be attached to this form. . 3. Other: 3 Page 4 of 1] OFFICIAL INSPECTION FORM—NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM'INSPECTION FORM PART A F.� CERTIFhCATION(continued) Property Address: i,, Owners ✓�Ze� J Date of Inspection:XLL,2 I'A D. System.Failure Criteria applicable to all systems: You must indicate"yes"or"no"to each of the following for all inspectio.n,s: Yes Ng! _ ��ackup of sewage into facility or system component due to overloaded or clogged SAS or cesspool _ 10 Discharge or..ponding of effluent to the surface of the around or surface waters due to an overloaded.or clogged SAS or cesspool G/ Static liquid level in the distribution box above outlet invert due to an overloaded or clogged SAS or _V/cesspool /Liquid depth in cesspool is less than 6"below invert or available volume is less than ''/day flow- _ equired pumping more than 4 times in the last year NOT due to clogged or,obstructed pipe(s).Number of times pumped YAny portion of the SAS, cesspool or privy is below high ground water elevation. Any portion of cesspool or privy is within 100 feet of a surface.water supply or tributary to a surface _ �,Vwater supply. Any portion of a cesspool or privy is within a Zone .I of a public well. .Any portion of a cesspool or privy is within 50:feet of a private water supply well. Any portion of a-cesspool or.privy is less than 160 feet but:greater than 50 feet from a private water supply well-with no acceptable water quality analysis. [This system passes if the well water analysis, performed ata'DEP certified laboratory,for coliform bacteria and volatile organic compounds indicates that the well is free from pollution from that facility and the presence of ammonia nitrogen and nitrate nitrogen.is equal to or,less than 5 ppm, provided that no other failure criteria are triggered.A copy of the analysis must be attached to this forma /VO (Yes/No)The system fails. I have determined that one or more of the above failure criteria exist as described in 310 CMR 15.303,.therefore the-system fails..The system owner should contact the Board of Health to determine what will be necessary to correct the failure. E. Large Systems: To be considered a.large'system the system must serve a facility with a-design flow of 10.,0010 gpd to 15,000 gpd You must indicate either"yes".or"no".to each of the following: (The following criteria apply-to large°systems in addition to the criteria above) yes no the system is within 400 feet of surface drinking water supply the system is within 200 feet of atributary to a surface drinking water supply the system is.located in a nitrogen sensitive area(Interim Wellhead Protection Area—IWPA)or a mapped Zone II of a public water supply well If you have answered"yes"to any question in Section E the system is considered a signifcantthreat, or answered "yes"in Section D above the large system has failed, The owner or operator of any large system considered a significant threat under Section E or failed under Section D shall upgrade.the:system in accordance with 3.10 CMR 15.304. The system owner.should contact the appropriate regional office of the Department. 4 Page 5 of 1.1 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS "SUBSURFACE SEWAGE WSFOSAL S.YSTE.M INSPECTION FORM PART B' CHECKLIST.,. Property Address: v 'l� _ ' � Owner Cd CGIUIU./ Date of Inspection: Check if the following have been done You must indicate"yes"or"no".as to each of the:following; _ Yes No Pumping.information.was provided by the owner, occupant,or.Board of Health: /Were.any of the system components pumped out in the previous'two weeks Has the system received normal flows.in the previous twomeek period? Have larce.volunies_of water been.introduced to the system recently or as part of this inspection? Were as built plans.of the system obtained and examined? (If they.were not available'note as N/A) Was the facility.or dwelling inspected for signs of sewage back up? w _✓ — Was the site inspected for signs of break out? , Were all system components, excluding the SAS, located on site. ✓_ Were the septic tank manholes uncovered,.opened; and the interior of the fank inspected for the condition of the baffles or tees,material of construction, dimensions,depth of liquid, depth.of sludge and depth of scum Was.the facility owner(and occupants if different from owner).provided with information on the proper maintenance of subsurface sewage disposal systems? g The size and location of the Soil Absorption System(SAS)on the site has.been determined based.on: Yes no Existing information. For example,a plan.at the Board of Health. Determined in the field(if any of the failure criteria related to Part C.is at.issue.approximation of distance is unacceptable) [3.10 CMR 15.302(3)(b)]. F a - j Page:6 of l I OFFICIALINSPECTION:FORM NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION Property Address � 0� � Owner: Ju CwP � Z'� Date of Inspection: 2 Q0 LOW CONDITION$ RESIDENTIAL t� • , r Number of bedrooms.(design)::. Number of bedrooms_(actual): . DESIGN flow based on 310 CMR 15.203 (for example: 11:0 gpd x#of bedrooms): ReO— Number of current residents: jG��� Does residence.have.a garbage grinder(.yes�or no d Is laundry on aseparate sewage`system (yes or no�l� :[if:yes separate inspection required] Laundry system inspected,(yes or no): tg< Seasonal use:,(yes or no):l ILA/G"a-, m c'-2c�o�PlY4 i -Water meter readings;if available (last 2 years usage(gpd)): Sump pimp(yes or no): f R Last date of occupancy.( • COMMERCIA`L/INDUSTRI Type of establishment:. Design flow(based on 310 CMR.15.20.3): gpd Basis of design flow(seats%persons/sgft;etc.): . Grease trap present(yes or no): Industrial waste.holding tank present(yes or no): Non-sanitary waste discharged to the Title 5 system(yes or no): Water meter readings, if available: Last date of occupancy/use: OTHER.,(describe): GENERAL INFORMATION Pumping Records Source of information: Was'system.pumped as.pW of th6 inspection(yes or noG, If.yes,volume pumped: .' gallons'.-_How was quantity pumped determined? Reason'for.pumping: TYPE OF SYSTEM _ eptic tank, distribution box,soil absorption system _Single cesspool Overflow cesspool Priory —Shared system (yes*or no)(if yes, attach previous inspection records, if any) Innovative/Alternative technology..Attach'a copy of the current operation and maintenance contract(to be obtained from system owner) Tight tank —Attach a copy:of the DEP.approval —Other'(describe): App oximate age of all components,date installed(if known)and source of information: Were'sewage odors'detected when arriving.at the site(yes or no): Page.7 of I 1 OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORNT. PART C . SYSTEM INFORMATION.(continued) Property Address (�( � �` -y`"' U .'V Y ",4 owner:h_ Date of Inspection: i7t� /h �1700 BUILDING SEWER(locate on site plan�60 Depth below grade: Materials of.construction:_cast-iron 40 PVC other(explain) Distance from private water supply well or suction line:' Comments(on condition of joints,venting, evidence of leakage,etc.): SEPTIC TANK: ✓ (locate on,site plan) A Loh J. n uw , !/ Depth below Arad Ub7,�dw Material of construction: oncrete_metal fiberglass_polyethylene —other(explain) If tank is metal list age:_ Is age confirmed by a Certificate of Compliance(yes or no): (attach a copy of certificate) _ Dimensions: `A ! ` Sludge depth: ?i,._/0 ri Distance from top of sludge to.bottom of outlet tee or baffle: �,� . } Scum thickness: Distance from top of scum to top of outlet tee or baffle: Distance from bottom.of.scum to bottom of outlet tee or baffle! How were dimensions determined: ,(CQ,f Comments (on pumping recommendations, inlet and outlet tee or baffle condition, structural integrity, liquid levels as related to outlet invert, evidence of leakage,etc: f OIL it GREASE TRAP/ ecateon.site plan) Depth below grade: Material of construction:_concrete_metal_fiberglass_polyethylene_other - (explain): Dimensions:. Scum thickness: Distance from top of scum-to.top.of outlet.tee or baffle: Distance from bottom:of scum to bottom of outlet tee or baffle: Date of last pumping: Comments(on pumping recommendations; inlet and outlet tee or bafe,condition,structural,integrity,liquid levels as related to outlet invert;evidence of leakage,etc.): - Page 8 of I I OFFICIAL INSPECTION FORM—.NOT FOR VOLUNTARY•ASSESSMENTS SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM'INFORMATION / (continued) Property Address: }-.. Owner: Date of;Inspection:4,���!y�P l�/a�(f ✓,// 0oo ram TIGHT or HOLDING TAN)�_�(tank must be pumped at time of inspection)(locate on site plan) Depth below grade: Material of construction: concrete metal fiberglass polyethylene other(ezplain): Dimensions: Capacity: gallons . Design Flow: gallons/day Alarm present(yes or no): Alarm level: Alarm in working order(yes or no): Date of last pumping: Comments (condition of alarm and float switches, etc.): DISTRIBUTION BOX: (if present must be opened)(locate on site plan) Depth of liquid level above outlet invert: Comments (note if box is level and distribution to outlets equal, any evidence of solids carryover;any evidence of leakage into or out of.box,etc.): � PUMP.CHAMBFR/. )<"`_(locate on site plan) Pumps in workinD order(yes or no): Alarms in working order(yes or no),:. } Comments(note condition of pump chamber,condition of pumps and appurtenances,etc.): 8 Page 9 of 11 OFFICIAL INSPECTION FORM=NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION.FORM PART C SYSTEM INFORALAXION(continued) Property Address: , i ")v 4 y . Ownera•_ - Date of Inspections J' 00 i SOIL ABSORPTION SYSTEM(SAS): locate on site plan,excavation not required) If SAS not located explain why: . Type eaching,pits,number: leaching chambers,number: leaching galleries,number: leaching trenches,number;length: leaching fields,number, dimensions: overflow cesspool,number: innovative/alternative system ,Type/name of technology: Comments(note condition of soil,signs of hydraulic failure, level of ponding, damp.soil;,condition of vegetation,.etc - mac.) r zki CESSPOOLS: -(cesspool must be pumped as part of inspection)(locate on site plan) :-Y Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer: Dimensions of cesspool: Materials of construction: Indication of groundwater inflow(yes or no): . Comments(note condition of soil, signs of hydraulic failure, level.of ponding,condition of vegetation; etc.): PRIVY j(locate on site plan) ' Materials of construction: Dimensions: Depth of solids:. Comments(note-condition of soil,signs of hydraulic failure, level of ponding,condition of'vegetation; etc.): 9 . Page 10 of 11 OFFICIAL INSPECTION FORM'-NOT FOR VOLUNTARY.ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: r &)W8e4 Date of Inspection: ��� - SKETCH OF SEWAGE DISPOSAL SYSTEM Provide a sketch of the sewage disposal system.including ties to at least two permanent reference landmarks or benchmarks. Locate all wells within 100 feet.Locate where public water supply enters the building. a d t 10 . Page I 1 of I 1 OFFICIAL INSPECTION FORM-NOT FOR VOLUNTARY ASSESSMENTS SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C SYSTEM INFORMATION(continued) Property Address: ' z``' a/�✓ .C- Owner Date of Inspection: cps SITE EXAM. Slope Surface water Check.cellar. Shallow wells Estimated depth to ground watery feet Please indicate(check)all methods used to determine the high ground water elevation: Obtained from system design plans on record-If checked, date of design plan reviewed:. Observed site(abutting property/observation hole within 150 feet of SAS) Checked.with local Board of Health-explain: hecked with local excavators, installers-.(attach documentation) Accessed USGS database-explain-, You must describe how you established the high ground water elevation: 6 © r eo zml _. • ? a Number D G•s T Com'cieteo oy: -. .. LlcLI GR0UiND L'`Vcl_ cc..%1'UTA T ION. /(�/ /�////) p/�^) ,/,may/�/:`/�J ///y• `T�/`'//��/A ///J/J n' _ ot Site Location: . i-4uc: Ovvner:_ Con_racior: 'm/` // �.C�6?✓�T, Address a' :': Notes: x-24- -STEP J Measures depth to water table ,. to nearest i/1.0 ...... ................ Da- A"' IL month/day/year STEP 2 Usi.ng UVatar.Level:Range Lone. . and Index Well Map.loca-e site and determine: OApprapri2te:index,well._ OW per-level range zone'—-,.... STEEP 3 Using.monthly report"Current W.atar,esources Conditions" de current deoLh:to Wate IeVSI TOf IntleY.WeII �- . - - rfionth/yaaf. f STEP' c Using T Qbie.orIIVo:ce Iwel'rAdjusftrnents \ nor lna x:welt(STEP 2 ):,-cu.rren�depth to water level ror-indaa well_(STEP 3), and water-level zone (S r,_P'23) determine wager=level adjustment .. ...._-.. ._....._ .__. .... . . ...._ ................... STEP., EssirrraLe depth to'nigh'water by'"subtractina-tne water- level adjustment(STEP 4); ' i • rrom measured w depth to ay r J� _ ram {ever at site (STEP 1) .......... .. ...... .........,..._.......: L Z ri0ure '13.=tr's9 rOCL'ClDI?CMDumion for rail. �''' Y � a f i 10 BORTOLUpp CO 'ST CT UTT 765 WAKEBY ROAUctMARSTONS MILLSv 1V1 t 4 �o 508-771-9399 508428 S926 FAX: 503 428-9. 91 SUBSURFACE SEWAGE DISPOSAL SYSTEM 1NSFECTI�N PART A CERTIFICATION Property Address: - Date of Inspection: YJ-)yZ9jL nspector's Name: Owner's N e and Add r ss: , CERTIFICATION STATEMENT: ' I certify that I have personally inspected the sewage disposal system at this address and that the informa- tion reported below is true,accurate and complete as of the time of insp:.cticn.The inspection was per- formed based on my training and experience in the proper function and anainrenance of on-site sewage disposal stems. The System: Passes Conditionally Passes Needs Further Ev lion ll a Local A rovin Authority, # ' .. � p g Fails 'Inspector's Signature: Date: The System Inspector shall submit a copy of this inspection report to the Approving authority within thir- ty(30)days of completing this inspection. If the system is a shared system or has a design flow of 10,000 gpd or greater,the inspector and the system owner shall submit the report to,the appropriate regional office of the Department of Environmental Protection. The original should be sent to the system owner and copies sent to the buyer,if applicable and the approving authority. INSPECTION SUMMARY: A)SYS�Ivl PASSES: ' . have not found any information which indicates that the systena violates any of the failure criteria as defined in 310 CMR 15.303. Any failure criteril a n:)t evaluated are indicated below. B)SYSTEM CONDITIONALLY PASSES; One or more system components need to be replaced or repairdl. The system,upon comple- r lion of the replacement or repair,passes inspection. Indicate yes,nor,or not determined(Y,N,OR ND). Describe basis of tieten Pi nation in all instances. If "not determined",.explain why not. The'septic tank is metal,cracked, structurally unsound,shows rulystantial infiltration or exfiltration,or tank failure is imminent. The system will ljas:.i nrcpection if the existing Sep- tic tank is replaced with a conforming septic tank as app:royee',try The Board of Health. Sewage backkup or breakout or high static water level observed ia the distribution box is due to broken or obstructed pipe(s)or due to a broken, settled or wiavo-m distribution box. The system will pass inspection if(with approval of The Board of t3mith):, - 1 - _ i ��.. �Q �z�i' ���A� � �'°" kf` >r� ';'!�'f� ..<,.�. „'ta .. .. - J is °r uvl, a { 1*•e, * i..,. ter• y 41, r 1 ' �' SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPF.CTI.ON.FORM PART A CERTIFICATION (continued) S � Broken pipe(s)replaced Obstruction is removed Distribution Box is levelled or replaced The System required pumping more than four times a year due to broken or obstructed pipe(s). The system•will pass inspection if(with approval of The Board of Health): Broken pipe(s)are replaced Obstruction is removed C)FURTHER EVALUATION IS REQUIRED BY THE BOARD OF HEALTH: Conditions exist which require further evaluation by The Board of Health in order to determine if ` 'the system is failing to protect the public health, safety and the environment. 4)SYSTEM WELL PASS UNLESS BOARD OF HEALTH DETERMINES THAT THE SYSTEM IS NOT FUNCTIONING IN A MANNER WHICH WILL PROTECT THE PUBLIC HEALTH AND SAFETY AND THE ENVIRONMENT: Cesspool or privy is within 50 Feet of a surface water f Cesspool or privy is within 50 Feet of a bordering vegetated wetland or a salt marsh. 4, 2)SYSTEM WILL FAIL UNLESS THE BOARD OF HEALTH. (AND PUBLIC WATER SUPPLIER,IF APPROPRIATE)DETERMINES THAT,THE SYSTEM IS FUNCTION- ING IN A;MANNER THAT PROTECT THE PUBLIC.HEALTH AND SAFETY AND,THE ENVIRONMENT: system has a septic tank and soil absorption system and is within 100 Feet to,a surface water supply or tributary to a surface water supply. The system has a septic tank and soil absorption system and is with a Zone I of a public water supply well.' The system has a septic tank and soil absorption system and is within 50 Feet of a private water supply well. The system has a septic tank and soil absorption system and is less than 100 Feet but•501 Feet or more from a private water supply well,unless a well water analysis for coliform bacteria and volatile organic compounds indicates that the well is free fromTpollution from lhe,facility and the presence of ammonia nitrogen.,and nitrate nitrogen is equal to or less n thangppm D)SYSTEM FAILS: I have determined that the system violates one or more of the following failure criteria as defined in 310 CMR 15.303. The basis for this determination is identified below: The Board of Health should be contacted to determine what will be necessary to correct the failure. Backup of sewage into facility or system component due to an overloaded or clogged SAS or cesspool. Discharge or ponding of efluent to the surface of the ground or surface waters due town " overloaded or clogged SAS or cesspool. Static.liquid level in the distribution box above outlet invert due to an overloaded or clog- ged SAS or cesspool. Liquid depth in cesspool is less than 6"below;invert or a vailable'volume is less than 1/2 ,�. day flow: . Required pumping more than 4 times in the last year NOT due to clogged or obstructed pipe(s). Number of times pumped -2- Al 1 { Zi SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART A CERTIFICATION (continued). . Any portion of the Soil Absorption System,cesspool or privy is below the high groundwater elevation. ; Any portion of a cesspool or privy is within 100 Feet of a surface water supply or tributary to a surface water supply. Any portion of a cesspool or privy is within a Zone I of a public well: Any portion of a cesspool or privy is within 50 Feet of a private water supply well. Any portion of a cesspool or privy is less than 100 Feet but greate 4han 50 Feet from a private water supply well with no acceptable water quality analysis. If the well has been analyzed to be acceptable,attach copy of well water analysis for coliform bacteria,volatile organic compounds,ammonia nitrogen and nitrate nitrogen. E)LARGE SYSTEM FAILS: The following criteria apply to a large system in addition to the criteria above: :'+ The design-flow of a system is 10,000 gpd or greater(Large System)and the system is a significant .. threat to public health and safety and the environment because one or more of the following ; tX conditions exist:. - The system is within 400 Feet of a surface drinking water supply The system is within 200 Feet of'a tributary to a surface drinking;water supply The system is located in a nitrogen sensitive area Interim Wellhead Protection Area (IWPA):or a mapped Zone II of a public water supply well. , The owner or operator of any such system shall bring the system and facility into full compLance with the groundwater treatment program Irequirements of 314 CMR 5.00 and 6.00.: Please consult the local F regional office of the Department for further information. SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM - PART B CHECKLIST Check if the following have b9n done. Pumping information was requested of the owner,occupant,and Board of.Health None of the system components have been pumped for atleast two wu'e}Ks and thesystem has, been receiving normal flow rates during that.period. Large volumes of.waterhave not been introduced into the system recently or as part of this inspection. :F As-built plans have been obtained and examined. Note if they are not available with N/A. The facility or dwelling was inspected for signs of sewage back-up. The system does not receive non-sanitary or industrial waste flow. Me site was inspected for signs of breakout. ✓All system components,excluding the Soil Absorption System,'have:been located on site. ✓fhe septic tank manholes were uncovered,opened,and the interio c of the septic tank was;in- spected for condition of baffles or tees,material of construction,dimensions,depth of liquid, depth of sludge;depth of's�um. The size and location of the Soil Absorption System on the site has been determined based on existing information or approximated by non-intrusive methods. -3_ 'iF tl G { SUBSURFACE.SEWAGEDISPOSAL SYSTEM INSPECTION FORM a PART B ' CHECKLIST(continued) The'facility owner(and occupants, if different from owner)were provided with information on f the proper maintenance of Subsurface Disposal System SUBSURFACE SEWAGE DISPOSAL SYSTEM INSPECTION FORM PART C _SYSTEM INFORMATION' / FLOW CONDITIONS RES11tE)!LT1ALi Design Flow: O Mons Number of Bedrooms: Number of Current Residents: . Garbage Grinder: Laundry.Connected To System: /tw Seasonal Use: - ,Garbage ilable: i Last Date of Occupancy: Vt&WAJ !1- O MER AIJINDLrSTRiAi�l� Type of Establishment:" Desi Flow rvF,ahons/da� ' Grease Trap Present: es or`no w' Y` p (y ) Industrial Waste Holding TanlePresent: Nori=Sanitary'Waste Discharged To The Title V System:, Water Meter Readings;If Available: Last Date of Occupancy: OTHER: Describe) a Last Date of Occupancy: GENERAL INFORMATION PUMPING RECORDS and source of information: `System Pumped as part-of inspection: If yes,volum pwnped. ::. gallons Reason for pumping. + TYPE� �PF SYSTEM• V Septic Tank/Distribution Box/Soil Absorption System Single Cesspool Overflow Cesspool Privy Shared System(If yes;attach previous inspection records,if any) Other(explain): .. ,... AP ROXIMATE'AGE of all components,date:installed(if known)and,so`urce of information: ... i Wit:• ....r, .. , ._ .,, .. _..a.... ;r; ' r Sew odors detected whenarriving at the sit !F'�t -SUBSURFACE SEWAGE DISPOSAL SYSTEM NN;PECTION FORM PART C GENERAL INFORMATION (cont�nuf d) SEPTIC TANK: 1/ Depth below grade Material of Construction: concrete metal FRP_Other , (explain) - Dimisions: 'QY,6' x 67, Sludge Depth: �� Scum Thi kness:_ /0 Distance from top of sludge to bottom of outlet tee or baffle: 33 Distance from bottom of scum to bottom of outlet tee or baffle:— 7�,___ Comments:-`rceommendation-for pumping;condition.of inlet and outlet tries or bt es,depth of liquid level in relation too tiet invert,structural 'ntegrity,evide .e of leakage,etc.) 4 . � GY 11 AIX + I GREASE`TRAP: Depth Below Grad Material of Construction:_concrete—metal FRP Other. (explain) Dimensions: Scum Thickuess: __�• Distance from top of scum to top of outlet tee or baffle: Comments:(recommendation for pumping,condition of inlet and outlet Ucs or.biffies,.depth of liquid level in relation to outlet invert,structural integrity,evidence of leakage,etc.)._ TIGHT OR HOLDING.TANK:A241 Depth Below Grade: Material of Construction:_concrete_metal__FRP Other(explain) Dimensions: Capacity: gallons Design Flow:_ __gallons/day Alarm Level: _ Comments: (condition of inlet tee,condition of alarm and float switches,etc-'=_, DISTRIBUTION BOX:� Depth of�liquid level above outlet invert: Comments: (note if 1 el and distribution is eq al evide a of solids car^���o;r,evidence of l ge into or out box,etc.) " _ PUMP CHAMBER• v Pump is in working order: _ Comments: (note condition of pump chaniber,•conditionofpumps and appui tenances,etc.) t • h - ,. 'd sw h w \ `e." i� I Y SUBSURFACE SEWAGE-DISPOSAL SYSTEM INSPECTION FORM PART C V SYSTEM INFORMATION (continued) SOIL,ABSORPTION SYSTEM(SAS): V-- Y 4' (Locate on site plan,if possible;excavation not required,but may be approximated by non-intrusive,. methods) If not determined to be present,explain: Type: Leaching pits,number: 2 Leaching chambers, number: Leaching galleries,number: Leaching trenches,number,length: Leaching fields,number,dimensions: !' Overflow cesspool,number: Commen `: (note condition of soil,signs of hydraulic failure level of ponding, ndition of v elation, etc. 1 i l CESSPOOLS: Number and configuration: Depth-top of liquid to inlet invert: Depth of solids layer: Depth of scum layer:..-` Dimensi6fis of Cesspool:. Materials of construction: Indication of groundwater: Inflow(cesspool must be•pumped as part of inspection) Comments: (note condition of soilk,signs of hydraulic failure, level of ponding;condition of vegetation, etc.) PRIVY: Materials-of construction: Dimensions: Depth of Solids: �} Comments: (note condition of soil,signs of hydraulic failure, level of ponding,condition of vegetation, etc.) -6- .i:- _..�4 t � '.�s TJ k,rFk'i '�q 7'•.. .. - .4 � 71°. ..1�.. tl ..i. "SUBSURFACE.SEWAGE,DISPOSAL S,YS'fEM INSPZCTION FORM PART C. SYSTEM INFORMATION (continueld)• SKETCH OF SEWAGE DISPOSAL SYSTEM: Include ties to atleast two permanent references, landmarks or benchmarks. Locate all wells within 100 Feet. .� � 3S g• ff r Uq O A- DEPTH TO GROUNDWATER: / Depth to groundwater: Feet / „ Method of Determination or Ap roxi ation: D Af4,*-"� -7- ;. .�'"E'°�►ti Town of Barnstable Public Health Division 200 Main Street p F Hyannis,MA 02601 z , �. . wrNEv:aowEs 02 1 A $ 00.390,, 0004606238 APR17 20071 MAILED FROM ZIP CODE 02601 l -5 pyO rasxz> 3139 1 0.7 04/ 21/0 j RETURN TO S'I2NDE-.R NO SUCH STRI=P-T Uhi�3F34..E TO FoRwgRD _.:•'J'�Yt]x.1-�•�I���g��AdV6 f����,1�Jr1,Jl,�1),,�,�11i�I„l)1�,,)1�,,,,l,�lll,,,ll,�,;l�.l�i mil l it lilt Mill ii l it i Certified Mail#7006 0810 0000 3524 9452 Town of Barnstable P Regulatory Services * BARNSTABLE, 9 IMAM Thomas F. Geiler,Director Alf°""A� Public Health Division Thomas McKean,Director 200 Main Street, Hyannis, MA 02601 . Office: 508-862-4644 Fax: 508-790-6304 April 12, 2007 Janet Murtha 137-River Isles Bradenton, FL 34208 NOTICE:,TO:,ABATE.,VIOLATIONS .OF 105 CMR 410.000, STATE..SANITARY. CODE II MINIMUM STANDARDS`OF FITNESS FOR`HUMAN'HABITATION AND-THE TOWN,OF_BARNSTABLE.CODE CHAPTER 170. :�.V_: J.,'.i.7 F. ,.•+ ....,+ C ,..+TJ .. 9. .�,'• Ft:^,.;1 > ri ` � T, i t ''Y. if f .".'V 3 » i t.yj-• The property owned by you'located'at 3�040 Falmouth Road Unit 1�4Marstons was inspected inspected on April 11, 2007 by Meredith Morgan, Health Inspector for the Town of Barnstable..:-:This inspection was conducted on the basis of the rental registration in accordance-with Chapter,170,,of the-Town of Barnstable Code:.{-;i ;a, The following violations of the Town,of Barnstable Code were observed: 1§ 70-10-Smoke Detectors and Carbon Monoxide Alarms. No CO detector. You are directed to correct the violations listed above within twenty-four (24) hours of your receipt of this.notice:by,installing CO,-detector in-accordance with Mass StaW;Fire,Codes• I.. S.; � r-_ �+°..S E"�v,: k..;r < (- You may request a Bearing before the Boar'd`•of Health if written petition requesting same ;.is received within ten(10) daysafter--.:the date the order is.serveda'_.s -, � c li ,_ :Non corrpliancekwill result m. a fine: of$100 00 per violation Each days failure-to comply with an order shall constitute a separate violation. Q:\Order letters\Housing violations\Rental ordinance\3040 Falmouth Road N4.doc Should you have any questions regarding the above violations, please contact the Town Health Division and ask to speak with the inspector who performed the inspection. ZPERDER OF THE B ARD OF HEALTH A. McKean, R.S., CHO Director of Public Health Town of Barnstable Cc: Rockey Dye, Tenant Cc: Meredith Morgan, Health Inspector Q:\Order letters\Housing violations\Rental ordinance\3040 Falmouth Road N4.doc i;